Nursing Elites

1. When reviewing the demographics of ethnic groups in the United States, which group does the nurse recall as the largest and fastest-growing population?

• A. Asian
• B. Hispanic
• C. American Indian
• D. African American/Black

Correct answer: B

Rationale: The correct answer is 'Hispanic.' Hispanics are the largest and fastest-growing population in the United States. While African Americans/Blacks, Asians, American Indians, and other groups are significant, Hispanics currently represent the largest demographic group. African American/Black, Asian, and American Indian populations are substantial but not as large or fast-growing as the Hispanic population. Therefore, Hispanic is the most appropriate choice in this scenario.

2. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?

• A. "I can always trust my family."?
• B. "It seems like I always have bad luck."?
• C. "You never know who will turn against you."?
• D. "I hear evil voices that tell me to do bad things."?

Correct answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.

3. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

4. Surgical asepsis is being performed when:

• A. wiping down exam tables with bleach
• B. sterilizing instruments
• C. changing table paper
• D. wearing gloves when performing injections

Correct answer: B

Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.

5. Which of the following statements best describes footdrop?

• A. The foot is permanently fixed in the dorsiflexion position
• B. The foot is permanently fixed in the plantar flexion position
• C. The toes of the foot are permanently fanned
• D. The heel of the foot is permanently rotated outward

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.

Similar Questions